Arterial Hyperoxemia During Cardiopulmonary Bypass Was Not Associated With Worse Postoperative Pulmonary Function: A Retrospective Cohort Study.

BACKGROUND: Arterial hyperoxemia may cause end-organ damage secondary to the increased formation of free oxygen radicals. The clinical evidence on postoperative lung toxicity from arterial hyperoxemia during cardiopulmonary bypass (CPB) is scarce, and the effect of arterial partial pressure of oxygen (Pa o2 ) during cardiac surgery on lung injury has been underinvestigated. Thus, we aimed to examine the relationship between Pa o2 during CPB and postoperative lung injury. Secondarily, we examined the relationship between Pa o2 and global (lactate), and regional tissue malperfusion (acute kidney injury). We further explored the association with regional tissue malperfusion by examining markers of cardiac (troponin) and liver injury (bilirubin). METHODS: This was a retrospective cohort study including patients who underwent elective cardiac surgeries (coronary artery bypass, valve, aortic, or combined) requiring CPB between April 2015 and December 2021 at a large quaternary medical center. The primary outcome was postoperative lung function defined as the ratio of Pa o2 to fractional inspired oxygen concentration (F io2 ); P/F ratio 6 hours following surgery or before extubation. The association between CPB in-line sample monitor Pa o2 and primary, secondary, and exploratory outcomes was evaluated using linear or logistic regression models adjusting for available baseline confounders. RESULTS: A total of 9141 patients met inclusion and exclusion criteria, and 8429 (92.2%) patients had complete baseline variables available and were included in the analysis. The mean age of the sample was 64 (SD = 13), and 68% were men (n = 6208). The time-weighted average (TWA) of in-line sample monitor Pa o2 during CPB was weakly positively associated with the postoperative P/F ratio. With a 100-unit increase in Pa o2 , the estimated increase in postoperative P/F ratio was 4.61 (95% CI, 0.71-8.50; P = .02). Our secondary analysis showed no significant association between Pa o2 with peak lactate 6 hours post CPB (geometric mean ratio [GMR], 1.01; 98.3% CI, 0.98-1.03; P = .55), average lactate 6 hours post CPB (GMR, 1.00; 98.3% CI, 0.97-1.03; P = .93), or acute kidney injury by Kidney Disease Improving Global Outcomes (KDIGO) criteria (odds ratio, 0.91; 98.3% CI, 0.75-1.10; P = .23). CONCLUSIONS: Our investigation found no clinically significant association between Pa o2 during CPB and postoperative lung function. Similarly, there was no association between Pa o2 during CPB and lactate levels, postoperative renal function, or other exploratory outcomes.

Successful treatment of pulmonary mucormycosis (Lichtheimia spp.) in a post-partum patient with COVID-19 ARDS requiring extra-corporeal membrane oxygenation using salvage therapy.

Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.

Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis.

BACKGROUND: Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients. METHODS: From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion. RESULTS: Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively. CONCLUSIONS: Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.

"Holes-in-one": A case of concurrent windsock mitral valve, root abscess, and Gerbode defect.

Infective endocarditis is a heterogeneous disease with a wide array of pathological lesions. We present a 55-year-old man with severe mitral and aortic regurgitation on transthoracic echocardiography. Transesophageal echocardiogram characterized the mechanisms detecting a windsock mitral valve perforation, aortic root abscess, and Gerbode ventricular septal defect, with the deep transgastric view showing all three pathologies concurrently. The etiologies of mitral valve perforation and Gerbode defects are discussed. Transesophageal echocardiography remains a critical imaging modality to diagnose and evaluate the extent of infective endocarditis with superior sensitivity to transthoracic echocardiography.

Cytomegalovirus immunoglobulin G titers do not predict reactivation risk in immunocompetent hosts.

Cytomegalovirus (CMV) reactivation occurs in roughly one-third of immunocompetent patients during critical illness, and is associated with worse outcomes. These outcomes have prompted consideration of early antiviral prophylaxis, but two-third of patients would receive unnecessary treatment. Tissue viral load has been associated with risk of reactivation in murine models, and recent work has suggested a relationship between immune responses to CMV and underlying viral load. We, therefore, sought to confirm the hypothesis that serum CMV-specific immunoglobulin G (IgG) correlates with tissue viral load, and might be used to predict the risk of reactivation during critical illness. We confirm that there is a good correlation between tissue viral load and serum CMV-specific IgG after laboratory infection of inbred mice. Further, we show that naturally infected outbred hosts have variable tissue viral DNA loads that do not correlate well with serum IgG. Perhaps as a consequence, CMV-specific IgG was not predictive of reactivation events in immunocompetent humans. When reactivation did occur, those with the lowest IgG levels had longer durations of reactivation, but IgG quartiles were not associated with differing peak DNAemia. Together our data suggest that CMV-specific IgG titers diverge from tissue viral loads in outbred immunocompetent hosts, and their importance for the control of reactivation events remains unclear.

Value of perioperative inhaled epoprostenol with low tidal volume ventilation for complex endocarditis surgery.

BACKGROUND AND AIM: To compare outcomes of patients treated with inhaled epoprostenol and low tidal volume ventilation during cardiopulmonary bypass with those who did not receive this medication in the operating room at all, and those who received it as a rescue therapy at the end of the case. METHODS: Retrospective chart review between 2014 and 2017, follow-up included the entire hospital stay. RESULTS: Seventy-one patients were included, and mean age was 54 years. 78.9% of the patients were male. Procedures included 96% (n = 68) aortic valve replacement, 28% (n = 20) reconstruction of the intravalvular fibrosa, and 13% (n = 9) repair of an endocarditis-related intracardiac fistula. Patients who received epoprostenol (iEpo) (treatment and rescue groups), when compared with the control group had more intra-aortic balloon pump placement (23% vs 2.5%, P = .018), open chest after surgery (32% vs 7.5%, P = .012), and duration of mechanical ventilation (8.3 ± 2.7 vs. 2.4 ± 0.4 days, P = 0.01). There was no significant difference between the two groups in terms of extracorporeal circulatory support (6.5% vs 2.5%, P = .577) and hospital death (13% vs 10%, P = .72). In a subanalysis, hospital death and duration of mechanical ventilation were higher in the recue group when compared with the treatment group (P = .004 and .056, respectively). CONCLUSIONS: Prophylactic application of iEpo with low tidal volume ventilation for an anticipated complex endocarditis operation may contribute to favorable outcome when compared with postoperative epoprostenol rescue.

Third time mitral valve replacement-lessons learned.

We report the management of three iatrogenic injuries involving the aortic valve, left circumflex artery, and left ventricular outflow tract, that occurred during a re-operative mitral valve replacement.

Mixed-species biofilm compromises wound healing by disrupting epidermal barrier function.

In chronic wounds, biofilm infects host tissue for extended periods of time. This work establishes the first chronic preclinical model of wound biofilm infection aimed at addressing the long-term host response. Although biofilm-infected wounds did not show marked differences in wound closure, the repaired skin demonstrated compromised barrier function. This observation is clinically significant, because it leads to the notion that even if a biofilm infected wound is closed, as observed visually, it may be complicated by the presence of failed skin, which is likely to be infected and/or further complicated postclosure. Study of the underlying mechanisms recognized for the first time biofilm-inducible miR-146a and miR-106b in the host skin wound-edge tissue. These miRs silenced ZO-1 and ZO-2 to compromise tight junction function, resulting in leaky skin as measured by transepidermal water loss (TEWL). Intervention strategies aimed at inhibiting biofilm-inducible miRNAs may be productive in restoring the barrier function of host skin.

A modified collagen gel dressing promotes angiogenesis in a preclinical swine model of chronic ischemic wounds.

We recently performed proteomic characterization of a modified collagen gel (MCG) dressing and reported promising effects of the gel in healing full-thickness excisional wounds. In this work, we test the translational relevance of our aforesaid findings by testing the dressing in a swine model of chronic ischemic wounds recently reported by our laboratory. Full-thickness excisional wounds were established in the center of bipedicle ischemic skin flaps on the backs of animals. Ischemia was verified by laser Doppler imaging, and MCG was applied to the test group of wounds. Seven days post wounding, macrophage recruitment to the wound was significantly higher in MCG-treated ischemic wounds. In vitro, MCG up-regulated expression of Mrc-1 (a reparative M2 macrophage marker) and induced the expression of anti-inflammatory cytokine interleukin (IL)-10 and of fibroblast growth factor-basic (ß-FGF). An increased expression of CCR2, an M2 macrophage marker, was noted in the macrophages from MCG treated wounds. Furthermore, analyses of wound tissues 7 days post wounding showed up-regulation of transforming growth factor-ß, vascular endothelial growth factor, von Willebrand's factor, and collagen type I expression in MCG-treated ischemic wounds. At 21 days post wounding, MCG-treated ischemic wounds displayed higher abundance of proliferating endothelial cells that formed mature vascular structures and increased blood flow to the wound. Fibroblast count was markedly higher in MCG-treated ischemic wound-edge tissue. In addition, MCG-treated wound-edge tissues displayed higher abundance of mature collagen with increased collagen type I : III deposition. Taken together, MCG helped mount a more robust inflammatory response that resolved in a timely manner, followed by an enhanced proliferative phase, angiogenic outcome, and postwound tissue remodeling. Findings of the current study warrant clinical testing of MCG in a setting of ischemic chronic wounds.

Pulmonary endarterectomy for subacute on top of chronic thromboembolic disease.

Our objective is to describe our approach for a case of subacute on top of chronic thromboembolic disease and highlight operative learning points. Prior to incision, appropriate monitoring equipment, including an arterial line, Swan-Ganz catheter, brain saturation monitor and bispectral index monitor, is placed for proper management of haemodynamics. Sternotomy was performed, and the ascending aorta was cannulated, followed by bicaval cannulation for venous drainage. The patient was cooled to deep hypothermia. Once target temperature was achieved, circulatory arrest commenced. The left pulmonary artery was opened and the subacute component was removed without disrupting the plane of the chronic thromboembolic disease. An endarterectomy plane was then created proximally and dissected into the distal segmental/subsegmental branches. Once the endarterectomy was completed, the left pulmonary artery was closed. Circulation was resumed for end-organ perfusion. Once the right pulmonary artery was ready for dissection, circulatory arrest was restarted. Similarly to the left side, the subacute component was removed without disrupting the plane of the chronic thromboembolic disease. An endarterectomy plane was then created proximally and dissected into the distal segmental/subsegmental branches. Circulation was then resumed. Once rewarmed to 35.5°C, the patient was decannulated and the sternum was closed.

Single vs Double Lung Transplantation in Older Adults: A Propensity-Matched Analysis.

BACKGROUND: Single lung transplantation (SLT) is associated with worse long-term outcomes than bilateral lung transplantation (BLT), but often is performed in older adults at risk of not tolerating BLT. RESEARCH QUESTION: How do the outcomes of SLT and BLT compare among older adult recipients? STUDY DESIGN AND METHODS: The Scientific Registry of Transplant Recipients database (2005-2022) was queried for lung transplant recipients 65 years of age or older. Patients were stratified by whether they underwent BLT or SLT and were propensity matched. Baseline characteristics and morbidity were compared with frequentist statistics. Survival was analyzed via Kaplan-Meier estimation. Risk factors for mortality were identified with Cox regression. RESULTS: Of 9,904 included patients, 4,829 patients (48.8%) underwent SLT. Patients who underwent SLT had lower lung allocation scores (39.6 vs 40.6; P < .001), more interstitial lung disease (74.4% vs 64.6%; P < .001), and lower rates of bridging (0.7% vs 2.4%; P < .001). Groups did not differ significantly by sex, BMI, or donor characteristics. Propensity matching resulted in 2,539 patients in each group. On matched analysis, patients undergoing SLT had shorter lengths of stay (14 days vs 18 day), lower reintubation rates (14.7% vs 19.8%), and less postoperative dialysis use (4.2% vs 6.4%; P < .001 for all). Patients who underwent SLT had comparable survival at 30 days (97.6% vs 97.3%; P = .414) and 1 year (85.5% vs 86.3%; P = .496), but lower survival at 5 years (45.4% vs 53.4%; P < .001) on matched analysis. SLT was a risk factor for 5-year mortality (adjusted hazard ratio, 1.19; P < .001). INTERPRETATION: In older adults, SLT is associated with less morbidity and comparable early survival relative to BLT, but lower 5-year survival. SLT is reasonable to perform in older adults at high risk of not tolerating BLT.

Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report.

Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.

Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery.

OBJECTIVE: An increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. METHODS: From January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non-long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan-Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. RESULTS: Of 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non-long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan-Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. CONCLUSIONS: Patients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.

Infective Endocarditis in Patients Addicted to Injected Opioid Drugs.

BACKGROUND: Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death. OBJECTIVES: The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors. METHODS: From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE). RESULTS: Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse. CONCLUSIONS: Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.

Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery.

BACKGROUND: Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. METHODS AND RESULTS: Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk [RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001). CONCLUSIONS: PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.

Multiarterial Grafting in Redo CABG: Type of Arterial Conduit and Patient Sex Determine Benefit.

OBJECTIVE: To evaluate whether multiarterial grafting provides incremental benefit above single arterial grafting in isolated redo CABG. METHODS: From 1/1980 to 7/2020, 6559 adults underwent 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity-score matched with those undergoing single arterial grafting, with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. Median follow-up was 10 years with 25% followed >17 years. Multivariable multiphase hazard modeling and nonparametric random survival forests for survival were used to identify patients for whom multiarterial grafting was most beneficial. RESULTS: Among propensity-matched patients, postoperative complications for multiarterial versus single arterial grafting were any reoperation, 50 (2.5%) versus 65 (3.2%); renal failure, 73 (3.6%) versus 55 (2.7%); stroke, 44 (2.2%) versus 38 (1.9%); and deep sternal infection, 36 (1.8%) versus 25 (1.2%). Hospital mortality was 1.7% (n=35) versus 2.8% (n=56) (P=.03). Comparing multiarterial to single arterial grafting, survival at 1 and 3 years was 95% versus 94% and 92% versus 88%, and at 5, 15, and 20 years, survival was 87%, 49%, and 31% versus 82%, 42%, and 25%. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P<.0001). CONCLUSIONS: Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used.

Contemporary experience with the Commando procedure for anterior mitral anular calcification.

Objective: Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods: From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results: Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions: The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.

A modified collagen gel enhances healing outcome in a preclinical swine model of excisional wounds.

Collagen-based dressings are of great interest in wound care. However, evidence supporting their mechanism of action is scanty. This work provides first results from a preclinical swine model of excisional wounds, elucidating the mechanism of action of a modified collagen gel (MCG) dressing. Following wounding, wound-edge tissue was collected at specific time intervals (3, 7, 14, and 21 days postwounding). On day 7, histological analysis showed significant increase in the length of rete ridges, suggesting improved biomechanical properties of the healing wound tissue. Rapid and transient mounting of inflammation is necessary for efficient healing. MCG significantly accelerated neutrophil and macrophage recruitment to the wound site on day 3 and day 7 with successful resolution of inflammation on day 21. MCG induced monocyte chemotactic protein-1 expression in neutrophil-like human promyelocytic leukemia-60 cells in vitro. In vivo, MCG-treated wound tissue displayed elevated vascular endothelial growth factor expression. Consistently, MCG-treated wounds displayed significantly higher abundance of endothelial cells with increased blood flow to the wound area indicating improved vascularization. This observation was explained by the finding that MCG enhanced proliferation of wound-site endothelial cells. In MCG-treated wound tissue, Masson's trichrome and picrosirius red staining showed higher abundance of collagen and increased collagen type I:III ratio. This work presents first evidence from a preclinical setting explaining how a collagen-based dressing may improve wound closure by targeting multiple key mechanisms. The current findings warrant additional studies to determine whether the responses to the MCG are different from other collagen-based products used in clinical setting.

First Case of Cupravidus paculus Infection in a Lung Transplant Recipient: A Case Report.

Cupravidus paculus is a rare Gram-negative bacterium that can cause a wide range of severe infections, largely in immunocompromised patients. It is a ubiquitous organism found in natural and man-made environments and in the hospital. Herein, we present the first case of C. paculus infection in a lung transplant recipient, which required prolonged antibiotic therapy to achieve complete clearance. Additionally, we review the existing literature on the clinical and microbiological profile of C. paculus, along with previously documented cases of clinical infections. Our case highlights the potential sources of C. paculus infections, the importance of appropriate disinfection protocols for medical devices, and the need for antibiotic sensitivities to guide treatment.

A 73-Year-Old Woman with a Fall.

A 73-Year-Old Woman with a FallA 73-year-old woman who had a cholecystectomy 2 months ago presented for evaluation after a fall. How do you approach the evaluation, and what is your differential diagnosis?